Provider Demographics
NPI:1851020598
Name:KACK, OLIVIA CLAIRE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CLAIRE
Last Name:KACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SALMON CREEK LN
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7861
Mailing Address - Country:US
Mailing Address - Phone:907-463-4040
Mailing Address - Fax:
Practice Address - Street 1:1200 SALMON CREEK LN
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7861
Practice Address - Country:US
Practice Address - Phone:907-463-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23700225X00000X
MN106839225X00000X
TX121038225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist